Pulmonary infection an atlas of investigation and management

Pulmonary Infection

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An Atlas of Investigation and Management

PULMONARY INFECTION

An Atlas of Investigation and Management

PULMONARY INFECTION Adam T Hill Consultant Physician Royal Infirmary of

Edinburgh Scotland

William AH Wallace Consultant Pathologist Royal Infirmary of Edinburgh Scotland

Xavier Emmanuel Consultant Microbiologist Royal Infirmary of Edinburgh Scotland

CLINICAL PUBLISHING OXFORD

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Atlas Medical Publishing Ltd 2005

First published 2005

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Clinical

Publishing or Atlas Medical Publishing Ltd. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or

editions any omissions brought to our attention.

A catalogue record for this book is available from the British Library.

ISBN 0-203-02493-1 Master e-book ISBN

ISBN - (Adobe eReader Format) ISBN 1 904392 19 9 (Print Edition)

The publisher makes no representation, express or implied, that the dosages in this book are correct. Readers must therefore always check the product information and clinical

procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publisher do not accept any liability for any errors in the text or for the

misuse or misapplication of material in this work.

Contents

Acknowledgements vi

Foreword vii

Abbreviations viii

1 Community-Acquired Pneumonia 1 2 Hospital-Acquired Pneumonia 41 3 Pneumonia in the Severely Immunocompromised Patient 49 4 Tuberculosis 73 5 Chronic Obstructive Pulmonary Disease 121 6 Bronchiectasis 130 7 Miscellaneous Respiratory Infections 149

Index 175

Acknowledgements

To our wives, Lucy, Amanda and Jacintha, for their continuous support and understanding without which this atlas and many other things would never have been successfully completed.

Foreword

Many of us have largely visual memories. This extensively illustrated book will make an immediate impact. For clinicians at any stage of training, that impact is likely to persist. Moreover the illustrations and their explanatory texts provide complementary reality behind the heavier paragraphs of standard textbooks. To more experienced clinicians, the book will be valuable as a reference, especially when they encounter less familiar clinical problems.

Conversely, trainees in microbiology, radiology, and pathology will here find a rapid insight into the potential contributions fellow disciplines can make to a diagnosis.

The brief texts on clinical and therapeutic aspects are written in clear straightforward English, again summarizing the essentials.

The authors and publisher have done an excellent job. I wish the book all the success it deserves,

Sir John Crofton Professor Emeritus

University of Edinburgh Scotland

Abbreviations AFB acid-fast bacilli

AIDS acquired immune deficiency syndrome

CFT complement fixation test

CMV cytomegalovirus

COPD chronic obstructive pulmonary disease

CT computed tomography

EGG electrocardiogram

ESAT early secretory antigenic target

FEV1 forced expiratory volume in 1 second

FiO2 inspired oxygen concentration

G-CSF granulocyte colony stimulating factor

IFN interferon gamma

i.v. intravenous

LDH lactate dehydrogenase

MOTT mycobacteria other than M. tuberculosis MRSA methicillin-resistant Staphylococcus aureus

NIV noninvasive ventilation

PaO2 partial pressure of arterial oxygen

PAS periodic acid Schiff

PCP Pneumocystis carinii pneumonia PCR polymerase chain reaction

SaO2 oxygen saturation

TB tuberculosis

TNF tumour necrosis factor

VAP ventilator-associated pneumonia

Chapter 1 Community-Acquired Pneumonia

Introduction

Internationally, community-acquired pneumonia is a common problem both for community and hospital physicians. It occurs with an annual incidence of about 511 per 1,000 adult population and rises with age, to about 34 per 1,000 population for patients aged over 75 years. The annual incidence of patients that require hospital admission varies from approximately 14 per 1,000 population. The mortality rates are low (50%. It is thus a common disease and can have considerable impact on health care resources.

This section on community-acquired pneumonia, with illustrative radiology, microbiology, and pathology, discusses the investigation, diagnosis, and management of community-acquired pneumonia in adults. Key areas covered include the common causative organisms, patient presentation including severity assessment, a recommended investigation strategy, and treatment options. Finally, the complications of community-acquired pneumonia are illustrated with particular emphasis on the investigation, diagnosis, and management of lung abscess and pleural infection.

Aetiology

In most cases of mild community-acquired pneumonia, a microbiological cause is not determined. When sputum samples are cultured by routine bacteriological methods, the commonest pathogen isolated is Streptococcus pneumoniae. Less commonly, Haemophilus influenzae or Moraxella catarrhalis may be cultured, particularly in patients with previous airways damage.

Some important respiratory pathogens cannot be cultured by routine methods, but are usually detected by immunological or molecular methods. These, the so-called atypical causes of pneumonia, include Mycoplasma pneumoniae, Legionella pneumophila, Chlamydia pneumoniae, Chlamydia psittaci, Coxiella burnetti, and respiratory viruses such as influenza viruses, adenoviruses, and respiratory syncytial virus.

Most organisms associated with mild pneumonia can also cause severe community-acquired pneumonia. Particularly severe pneumonia with septic shock may result when viral infections, such as influenza, lead to secondary lung infections with virulent pathogens such as Streptococcus pneumoniae, Staphylococcus aureus, or Streptococcus pyogenes.

Presentation

Patients may have had preceding viral upper respiratory tract symptoms. New onset of lower respiratory tract symptoms occurs (usually coughsputum

production [sometimes haemoptysis], breathlessness, fever, and sometimes pleurisy). Systemic features are often present (general malaise, anorexia, sweating, fevers, shivers,

or aches and pains). Extrapulmonary symptoms can be present. New onset confusion can arise in severe cases. New focal chest signs occur. The clinical signs in practice can be highly variable (the

classical teaching in lobar pneumonia is reduced expansion, coarse inspiratory crackles, reduced percussion, bronchial breathing, and increased vocal resonance in the affected lobe).

New chest radiographic consolidation is present. There is no other explanation for illness.

Overall, the likely aetiological agent cannot be accurately predicted from clinical features.

Severity score

To guide placement and treatment, it is helpful to stratify patients according to illness severity. Patients with severe pneumonia have two or more of the following:

New onset mental confusion. Blood urea >7 mmol/l. Respiratory rate 30/min. Systolic blood pressure